Friday, August 05, 2011

County Wide Hospital Ban on Early Inductions in Portland

Beginning September 1, 2011 birthing may be a little less "convenient" for some in Multnomah County, but a greater percentage of the babies born there will be healthy as a result of a historic agreement reached this week among local hospitals.

All 17 Portland-area hospitals have agreed to put what they call a “hard stop” on elective induction and caesarian section births before 39 weeks, unless those inductions are medically necessary.

Induced births and unnecessary c-sections have been a controversial issue for years in health care circles. Rates of elective inductions and c-sections have continued to rise even as a growing collection of data has made clear that early births sacrifice the health of newborns and add to overall health care spending.

Pregnant women often want to schedule births to make them more convenient for out-of-town family members. Obstetricians have been known to suggest inducing births that might be just a day or two before 39 weeks so that they can deliver on a Friday afternoon, for instance, rather than be called into the hospital on a weekend or during the middle of the night.

In addition, hospitals find they can operate more cost effectively by scheduling births, and women sometimes induce because they want their regular obstetrician to deliver the baby, rather than any physician who might be on call.

Wednesday’s announcement, through the Oregon chapter of the March of Dimes, means that induced births even one day before 39 weeks will now require patients to present their case to a designated arbiter at the hospital and prove that there is a medical reason why the early birth should take place.

“We’ve become accustomed to being able to schedule our lives, especially moms,” says Joanne Rogovoy, spokeswoman for the March of Dimes greater Oregon chapter. “When they learn why the last weeks of pregnancy are so important, especially with brain development, I believe they will embrace the concept that healthy babies are worth the price.”

Until recently, most physicians did not believe that a birth at 38 weeks and six days had a significant difference from a birth at 39 weeks, says Dr. Duncan Neilson, clinical vice president of Legacy Medical Groups and chief of women’s services.

But new research has shown that there is significant brain development going on right through 38 weeks. Babies born before 39 weeks of pregnancy are two to three times more likely to be admitted to intensive care as well as have trouble breathing, according to recent studies.

Salmon Creek Medical Center, a Legacy hospital in Vancouver, Wash., studied the problem on its own earlier this year and found that 42% of its babies born electively did not meet the criteria for medical exceptions. In April, Salmon Creek instituted its own hard stop on induced births before 39 weeks.

Neilson says the new policy will require some adjustment from pregnant women. “There are huge pressures to deliver just a little bit early,” he says. A common request, Neilson says, is from women whose husbands have been given a short leave from the war in Afghanistan, and don’t want to go back without spending time with their newborn baby. Neilson says that under the new agreement, even those parents won’t be able to induce an early birth because the births won’t be medically necessary.

Neilson says that getting all area hospitals to sign on to the agreement was crucial. If even one or two had refused to commit, Neilson says, that would have undermined the others by providing a local option for women wanting to induce for convenience’s sake.

“This is unprecedented in the Portland area,” Neilson says of the agreement. “Hospitals often compete, but this is a case where collaboration is the only way to improve the performance.”

Dr. Aaron Caughey, chairman of the ob/gyn department at OHSU, says some physicians still haven’t gotten the message that there is a significant health risk in delivering babies even a few days before the 39th week. And some families have personal reasons for wanting to schedule births on specific dates.

For instance, Caughey says, certain numbers are considered lucky in some cultures. Caughey says that on Aug. 8, 2008, he had a number of Asian women who wanted to induce labor because of the significance of the date.

From a hospital’s point of view, Caughey says, the new ban on inducements will create inefficiencies to which they will have to adjust. “In running labor and delivery units scheduling is everything,” Caughey says. “Unfortunately, we know the more we schedule the birth experience and interventions, we don’t improve outcomes, and sometimes we lead to worse outcomes.”

Scheduling births when rooms and physicians are available may increase hospital efficiency, but it doesn’t lower costs, according to a study earlier this year out of Utah.

Intermountain Healthcare, a consortium of 23 hospitals there, put a hard stop on elective inductions at all its facilities after discovering that babies born at 38 weeks needed newborn intensive care for breathing problems twice as frequently as those born at 39 weeks or longer.

By instituting a ban on inductions before the 39th week, Intermountain kept an estimated 500 newborns from having to use ventilators after birth and saved at least $1 million in health care costs in one year, according to hospital officials. Fewer inductions also resulted in fewer overall c-sections, according to Intermountain. And that resulted in an additional savings of over $45 million.

Caughey says he hopes the new agreement also leads to a reduction in unnecessary c-sections. A study this year to which OHSU researchers contributed concluded that c-section rates are rising so quickly in the United States, that by the year 2020 they could account for 56% of all U.S. births. The World Health Organization recommends that no country exceed a c-section rate of more than 15% max, but the current U.S. rate, which has been steadily climbing for decades, now stands at about 33%. [Most home birth midwives attending birth in the U.S. have a c-section transfer rate of 3-8%.]

Good for Portland!!! Hopefully other hospitals will start to follow suit. When I had my first daughter, my midwives informed me that they absolutely would not induce for nonmedical reasons. When I had my second daughter, my doctor was talking about inductions even before my due date because there were "several other women" due to give birth the week after I was and she didn't want all of us in labour at the same time. I was very happy when my daughter decided to come, on her own, on the weekend that doctor was out of town.

Portland has celebrity clients? I'm due on September 9th and it is interesting how this is being danced around. My first was low-risk and I had a hospital birth with a CNM.My daughter was 17 days "late" and just over 10 pounds. Now, 5 years later, I am "high-risk," due to an autoimmune disease and an unexplained stillbirth. Although this pregnancy has been completely issue-free, I get the idea that I will not be "allowed" to go into labor naturally. Should be an interesting several weeks!

What would you do if you go to the hospital for a routine u/s at 38 weeks and they say to you that you should get a c-section because your baby is in breech and you don't have enough amniotic liquid. Like you should get a c-section ASAP because there are risks for baby because of the low level of amniotic liquid and anyway you will get a c-section anyway even if you wait because your baby has no place to move.

Please keep in mind that 100% of breech cases are delivered by c-section where I live. I also wonder where I should find such information. I found plenty of information about breech babies and low level of amniotic liquid but not the two together. If you have a link please tell me!

Hmm...I love this but wonder who gets to say what the due date is. I've heard of doctors switching due dates around even at the end of pregnancies. Seems like a loophole but I'm sure the hospitals will note if a specific doctor is doing inductions and the babies are popping out underbaked =).

I agree that I think there will be a sudden rise in "medical necessity". I also think that 39 weeks is too early unless there is medical necessity. My SIL was induced right at 39 wks... failed induction, c-section, baby in the NICU because he was forgetting to breath while nursing, and a mama being told that a 7 lb 13 oz baby is too BIG for her to birth... ugh!

Because of that, plus my own intuition, A LOT of research and some luck I went to 43 wk 3 days with my daughter. I shudder to think what would have happened if I'd listened to "conventional wisdom" and induced her "on time".

Sorry to inform you, but Portland is not leading the way. This is standard in TX now as well. I live in the Houston area. There is a sign in my OB's office now stating that unless it is medically necessary, no inductions before 39 weeks, because of changes in the requirements from the insurance companies. This has been there for probably a year now. My ob really likes to do inductions actually, which is sort of why I chose him. My body doesn't seem to want to give my kids up easily, so I have been induced with 3 out of 4. The one that wasn't induce I still had to have pitocin after over 24 hours of labor, so I figure, that is just the way with me. My boys were the only ones I had early. My first at 10 days early because that doc(different than current) said he was going to be big, and he came in at 8 lbs 2.7oz, and he did fine(except for having the cord around his neck, but that is unrelated). The other one was 15 days early because my other children were big as well, girl - 3 days late and 8 lbs 2.7 oz, girl - 4 days late and 9 lbs. Anyway, the boy that was 15 days early was 7 lbs 4 oz. He did stay in the NICU for 6 days because anytime someone would touch him or do anything to him he would breath to fast. But I really do think this would have happened anytime he was born, especially now that I have know him for 16 months. He just does that when he gets excited. Oh, and it was a really rough pregnancy for me as well. Depression started halfway through, low blood pressure(I had to have ephedrine when I was in labor with him because my blood pressure tanked to something like 84/40), kidney stones, etc. I was just really done.

I guess that this is the long way for me to say that I also understand why some women choose to have their babies early. My next one in January I will go the 40 weeks though, because of pressure from my family, and really, this pregnancy is going WAY better than my last.

The fine print here is "before 39 weeks." That means that up to a week before the estimated Due Date would be allowed?

My son was born, in Portland, a few days before his due date. My doctor was suggesting induction for a couple days after that though. I was 'done' being pregnant, and my husband and I were both super excited to meet our son, but I am SO glad now that I wasn't induced. And angry that my doctor was willing to push an induction on me when I so obviously didn't need one. When I asked her if inductions increased my c-section risk, she flat-out told me no, which I know now to be completely untrue.

For what it's worth, my due date was also changed around a lot, as there was some confusion as to when exactly my son was conceived. That isn't uncommon, making it easy for a 39 week induction to actually be a 38 week one. Not to mention that 40 weeks isn't always full term -- The body KNOWS when to give birth!